Vaginal bleeding in pregnancy (less than 20wks): Difference between revisions

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===Background===
==Background==
# Occurs in 20-40% of 1st trimester pregnancies
[[File:Pregnancy timeline.png|thumb|Timeline of pregnancy, including (from top to bottom): Trimesters, embryo/fetus development, gestational age in weeks and months, viability and maturity stages.]]
# Once IUP is confirmed by ultrasound no utility in obtaining B-hCG
[[File:2904 Preembryonic Development-02.jpg|thumb|Pre-embryonic development.]]
# Ultrasound
[[File:Maternity and child care (1920) (14593999138).jpg|thumb|Cross section of pregnant uterus (second month of gestation): 1—Wall of uterus. 2—Beginning of fal-lopian tube. 3—Placenta showing branches of villi.4—Umbilical cord. 5—Fetus. 6—Amnionicfluid or bag of waters. 7—Amnionicmembrane. 8—Chorionic membrance.9—Cervix or mouth of uterus.]]
## Do not use hCG to determine whether ultrasound should be obtained
[[File:Bumm 123 lg - Copy.jpg|thumb|Estimated gestational age based on physical exam.]]
### "Discrimatory Zone" values are for IUP visualization, not ectopic visualization
*Occurs in 20-40% of 1st trimester pregnancies
#### Pelvic - can visualize IUP at hCG ~ >1500
*Once IUP is confirmed by [[ultrasound]] no utility in obtaining [[B-hCG]]
#### Abd - can visualize IUP at hCG ~ >6000
*US
**Do not use hCG to determine whether [[ultrasound]] should be obtained


===DDX===
{{Abortion types}}
# Ectopic Pregnancy
## hCG > 1500 + no IUP
# Miscarriage
## Complete Abortion
### <12 weeks + no IUP
### Distinguish from ectopic based on decreasing hCG, decreased bleeding
#### Only need to send hCG if unable to examine POC
## Threatened Abortion
### Closed os + IUP + cramps and/or bleeding
### If < 11wks >90% go to term
### If between 11 and 20 weeks 50% go to term
## Inevitable Abortion
### Open os + contractions/cramps
## Incomplete Abortion
### >12 wks + passage of only portion of POC
## Missed Abortion
### <20 wks + no cardiac activity
# Non-pregnancy related bleeding
## Cancer
## Fibroids
## Cervicitis


===Evaluation===
==Clinical Features==
# History
===History===
## Previous spontaneous abortion?
*Previous spontaneous abortion
## Extent of bleeding, clots, tissue
*Extent of bleeding, clots, tissue
## Presence of cramping
**Often quantified by pads per hour, greater than 1 per hour is concerning
## Light-headedness?
*Presence of cramping
## Risk Factors for Ectopic
*Light-headedness? [[Chest pain]]? [[Shortness of breath]]? [[Palpitations]]?
### PID
### IUD
### Adnexal surgery
# Physical
## Uterus able to palpated in abdomen ~ 12 weeks
## Uterus able to visualzed by abdominal ultrasound ~ 10 weeks
## Open OS decreases, but does not rule-out, ectopic
## If find POC send to pathology to rule-out trophoblastic disease


===Work-Up===
===Physical===
# B-hCG (quant)
*Uterus able to palpated in abdomen ~ 12 weeks
# CBC
*Uterus able to visualzed by abdominal ultrasound ~ 10 weeks
# T&S (Rh) vs. T&C
*Open os decreases, but does not rule-out, [[ectopic]]
# IVF vs. blood
*If products of conception obtained send to pathology to rule-out trophoblastic disease
# UA
*Can quantify amount of bleeding by number of scopettes of blood on pelvic exam
# RhoGAM if indicated
*Large subchorionic hemorrhage increases chances of a [[First Trimester Abortion|miscarriage]]
# Hemabate/Pitocin if indicated
 
# Ultrasound
{{Pregnancy vitals}}
## IUP = Threatened AB
{{Fundal height in pregnancy}}
### Ectopic ruled-out unless on fertility drugs
## Empty uterus + free fluid/adnexal mass = Ectopic
## Empty uterus + no free fluid / no mass<nowiki>:</nowiki>
### BHC-G:
#### >6,000 = Ectopic
#### 1,000 - 1,500 = indeterminante (?D&C if undesired)
#### <1,500 = follow serial B-HCG levels (x 48hrs)
##### Increased >66% = nL IUP
##### Increased < 66% = Ectopic


===Source===
==Differential Diagnosis==
UpToDate, Rosen's
{{VB DDX less than 20}}


[[Category:OB/GYN]]
==Evaluation==
''See also [[maternal vitals and labs in pregnancy]]''
===Work-Up===
*[[Beta-HCG Levels|B-hCG (quantitative)]]
*CBC and BMP
*Coags
*T&S (Rh) vs. T&C
*[[Urinalysis]]
*[[Ultrasound: Pelvic|Pelvic ultrasound]]


===Diagnosis===
====Diagnostic Algorithm====
*By [[ultrasound]] finding:
**+IUP = [[threatened abortion]]
***[[Ectopic]] ruled-out unless on fertility drugs
**Empty uterus + free fluid/adnexal mass = [[Ectopic]]
**Empty uterus + no free fluid / no mass
***[[Beta-HCG Levels|Beta-HCG]]:
****>1,500 = Presumed [[ectopic]]
****<1,500 = Indeterminate: follow serial [[B-HCG]] levels in 48hrs (if no peritonitis)
*****Increased >66% = normal IUP
*****Increased <66% = [[Ectopic]]


====Discrimatory Zone<ref>Ankum WM, Van der Veen F, Hamerlynck JV, Lammes FB. Suspected ectopic pregnancy. What to do when human chorionic gonadotropin levels are below the discriminatory zone. J Reprod Med. 1995;40:525–8</ref>====
''Values are for IUP visualization, not ectopic visualization''
*Pelvic Ultrasound: hCG >1500
*Abd Ultrasound: hCG >3000<ref>Wag, R. et al. Use of a !-hCG Discriminatory Zone With Bedside
Pelvic Ultrasonography. Annals of Emergency Medicine. 58(1)12-20. [http://emupdates.com/perm/Wang%20Discriminatory%20Zone%202011%20AnnEM.pdf PDF]</ref>


===Background===
==Management==
* Occurs in 20-40% of 1st trimester pregnancies
#[[Rho(D) Immune Globulin (RhoGAM)|RhoGAM]] if Rh Negative
* Once IUP is confirmed by ultrasound no utility in obtaining B-hCG
#*ACOG Clinical practice guideline recommends forgoing routine Rh testing and RhIg administration at <12 weeks of gestation<ref>(2024). ACOG Clinical Practice Update: Rh D Immune Globulin Administration After Abortion or Pregnancy Loss at Less Than 12 Weeks of Gestation. Obstetrics & Gynecology, 144 (6), e140-e143. doi: 10.1097/AOG.0000000000005733.</ref>
* Ultrasound
#Assess need for transfusion (severe anemia or hypotension)
** Do not use hCG to determine whether ultrasound should be obtained
#Treat specific process:
*** "Discrimatory Zone" values are for IUP visualization, not ectopic visualization
#*[[Ectopic]]
**** Pelvic - can visualize IUP at hCG ~ >1500
#*[[Threatened abortion]]
**** Abd - can visualize IUP at hCG ~ >6000
#*Indeterminate
#**Follow serial [[B-HCG]] levels in 48hrs (if no peritonitis)
#**If peritonitis/surgical abdomen, immediate OB/GYN consult for possible [[ectopic]]


===DDX===
==Disposition==
* Ectopic Pregnancy
*Admit for:
** hCG > 1500 + no IUP
**[[Ectopic]]
* Miscarriage
**Life threatening bleeding
** Complete Abortion
**Surgical abdomen
*** <12 weeks + no IUP
*** Distinguish from ectopic based on decreasing hCG, decreased bleeding
**** Only need to send hCG if unable to examine POC
** Threatened Abortion
*** Closed os + IUP + cramps and/or bleeding
*** If < 11wks >90% go to term
*** If between 11 and 20 weeks 50% go to term
** Inevitable Abortion
*** Open os + contractions/cramps
** Incomplete Abortion
*** >12 wks + passage of only portion of POC
** Missed Abortion
*** <20 wks + no cardiac activity
* Non-pregnancy related bleeding
** Cancer
** Fibroids
** Cervicitis


===Evaluation===
==See Also==
* History
{{DDX undifferentiated VB}}
** Previous spontaneous abortion?
** Extent of bleeding, clots, tissue
** Presence of cramping
** Light-headedness?
** Risk Factors for Ectopic
*** PID
*** IUD
*** Adnexal surgery
* Physical
** Uterus able to palpated in abdomen ~ 12 weeks
** Uterus able to visualzed by abdominal ultrasound ~ 10 weeks
** Open OS decreases, but does not rule-out, ectopic
** If find POC send to pathology to rule-out trophoblastic disease


===Work-Up===
==External Links==
* B-hCG (quant)
*https://bridgetotreatment.org/resource/ectopic-pregnancy-in-the-ed-unrestricted/
* CBC
*https://bridgetotreatment.org/resource/ed-management-of-early-pregnancy-loss-misoprostol-protocol/
* T&S (Rh) vs. T&C
* IVF vs. blood
* UA
* RhoGAM if indicated
* Hemabate/Pitocin if indicated
* Ultrasound
** IUP = Threatened AB
*** Ectopic ruled-out unless on fertility drugs
** Empty uterus + free fluid/adnexal mass = Ectopic
** Empty uterus + no free fluid / no mass<nowiki>:</nowiki>
*** BHC-G:
**** >6,000 = Ectopic
**** 1,000 - 1,500 = indeterminante (?D&C if undesired)
**** <1,500 = follow serial B-HCG levels (x 48hrs)
***** Increased >66% = nL IUP
***** Increased < 66% = Ectopic


===Source===
==References==
UpToDate, Rosen's
<references/>


[[Category:OB/GYN]]
[[Category:OBGYN]]

Latest revision as of 23:07, 22 October 2025

Background

Timeline of pregnancy, including (from top to bottom): Trimesters, embryo/fetus development, gestational age in weeks and months, viability and maturity stages.
Pre-embryonic development.
Cross section of pregnant uterus (second month of gestation): 1—Wall of uterus. 2—Beginning of fal-lopian tube. 3—Placenta showing branches of villi.4—Umbilical cord. 5—Fetus. 6—Amnionicfluid or bag of waters. 7—Amnionicmembrane. 8—Chorionic membrance.9—Cervix or mouth of uterus.
Estimated gestational age based on physical exam.
  • Occurs in 20-40% of 1st trimester pregnancies
  • Once IUP is confirmed by ultrasound no utility in obtaining B-hCG
  • US
    • Do not use hCG to determine whether ultrasound should be obtained

Abortion Types

Classification Characteristics OS Fetal Tissue Passage Misc
Threatened Abdominal pain or bleeding; < 20 weeks gestation Closed No If < 11 weeks (with fetal cardiac activity) 90% progress to term. If between 11 and 20 weeks 50% progress to term
Inevitable Abdominal pain or bleeding; < 20 weeks gestation Open No
Incomplete Abdominal pain or bleeding; < 20 weeks gestation Open Yes, some
Complete Abdominal pain or bleeding; < 20 weeks gestation Closed Yes, complete expulsion of products Distinguish from ectopic based on decreasing hCG and/or decreased bleeding
Missed Fetal death at <20 weeks without passage of any fetal tissue for 4 weeks after fetal death Closed No
Septic Infection of the uterus during a miscarriage. Most commonly caused by retained products of conception Open No, or may be incomplete Uterine tenderness and purulent discharge from the OS may be present

Clinical Features

History

  • Previous spontaneous abortion
  • Extent of bleeding, clots, tissue
    • Often quantified by pads per hour, greater than 1 per hour is concerning
  • Presence of cramping
  • Light-headedness? Chest pain? Shortness of breath? Palpitations?

Physical

  • Uterus able to palpated in abdomen ~ 12 weeks
  • Uterus able to visualzed by abdominal ultrasound ~ 10 weeks
  • Open os decreases, but does not rule-out, ectopic
  • If products of conception obtained send to pathology to rule-out trophoblastic disease
  • Can quantify amount of bleeding by number of scopettes of blood on pelvic exam
  • Large subchorionic hemorrhage increases chances of a miscarriage

Normal Vitals in Pregnancy[1]

Vital Nonpregnant 1st Trimester 2nd Trimester 3rd Trimester
HR 70 78 82 85
SBP 115 112 112 114
DBP 70 60 63 70
Hcrt 40 36 33 34
WBC 7.2k 9.1k 9.7k 9.8k

Estimated Gestational Age by Fundal Height[2]

Weeks Fundal Height / Finding
12 Pubic symphysis
20 Umbilicus
20-32 Height (cm) above symphysis = gestational age (weeks)
36 Xiphoid process
>37 Regression
Post delivery Umbilicus

Differential Diagnosis

Vaginal Bleeding in Pregnancy (<20wks)

Evaluation

See also maternal vitals and labs in pregnancy

Work-Up

Diagnosis

Diagnostic Algorithm

  • By ultrasound finding:
    • +IUP = threatened abortion
      • Ectopic ruled-out unless on fertility drugs
    • Empty uterus + free fluid/adnexal mass = Ectopic
    • Empty uterus + no free fluid / no mass
      • Beta-HCG:
        • >1,500 = Presumed ectopic
        • <1,500 = Indeterminate: follow serial B-HCG levels in 48hrs (if no peritonitis)
          • Increased >66% = normal IUP
          • Increased <66% = Ectopic

Discrimatory Zone[3]

Values are for IUP visualization, not ectopic visualization

  • Pelvic Ultrasound: hCG >1500
  • Abd Ultrasound: hCG >3000[4]

Management

  1. RhoGAM if Rh Negative
    • ACOG Clinical practice guideline recommends forgoing routine Rh testing and RhIg administration at <12 weeks of gestation[5]
  2. Assess need for transfusion (severe anemia or hypotension)
  3. Treat specific process:

Disposition

  • Admit for:
    • Ectopic
    • Life threatening bleeding
    • Surgical abdomen

See Also

Vaginal bleeding (main)

External Links

References

  1. ↑ Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol 2009; 113:1299-1306.
  2. ↑ Vasquez V, Desai S. Labor and delivery and their complications. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier Saunders; 2018:2296–2312.
  3. ↑ Ankum WM, Van der Veen F, Hamerlynck JV, Lammes FB. Suspected ectopic pregnancy. What to do when human chorionic gonadotropin levels are below the discriminatory zone. J Reprod Med. 1995;40:525–8
  4. ↑ Wag, R. et al. Use of a !-hCG Discriminatory Zone With Bedside Pelvic Ultrasonography. Annals of Emergency Medicine. 58(1)12-20. PDF
  5. ↑ (2024). ACOG Clinical Practice Update: Rh D Immune Globulin Administration After Abortion or Pregnancy Loss at Less Than 12 Weeks of Gestation. Obstetrics & Gynecology, 144 (6), e140-e143. doi: 10.1097/AOG.0000000000005733.
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